BJMS Borneo Journal of Medical Sciences

ORIGINAL ARTICLE

Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, , Asong Joseph1*, Helen Benedict Lasimbang2, Sandi James3, Chua Bee Seok1

ABSTRACT 1 Faculty of Psychology and Education, Universiti Malaysia Sabah, , Sabah, Malaysia Alcohol consumption has consequences for 2 Department of Reproductive Health, the health and quality of life of individuals and Faculty of Medicine and Health Sciences, communities. It is a problem among some of the Universiti Malaysia Sabah, Indigenous groups of Sabah and Sarawak with Kota Kinabalu, Sabah, Malaysia some of the highest prevalence of risky drinking 3 Faculty of Health, Science and Engineering, in Malaysia. Alcohol is considered to be part of La Trobe University, Victoria, Australia the culture of some of these Indigenous groups and a way to maintain the connection to their culture and traditions. However, drinking too * Corresponding author’s email: much on a single occasion and drinking regularly [email protected] over time is not a part of the culture. Therefore, this study aimed to investigate the positive and Received: 10 October 2019 negative effects of alcohol on quality of life (QoL) of an Indigenous community of Sabah. A Accepted: 10 March 2020 total of 56 villagers from the West Coast Division of Sabah were interviewed in focus group discussions using the diamond dialogue tool. Data were analysed using thematic analysis and revealed that alcohol consumption has both beneficial and adverse effects on health, behavioural, social, economic and psychological factors, depending on the drinking patterns. These harmful results suggest that awareness and harm-reduction programmes may help to empower the Indigenous groups of Sabah to reduce alcohol-related harm.

INTRODUCTION Keywords: alcohol consumption, alcohol-related harm, quality of According to the World Health Organization life, Indigenous group, traditional (WHO), alcohol is the world’s third-largest risk alcohol, Diamond Dialogue tool factor fordisease burden1. In 2016, alcohol was reported as representing 132.6 million disability-adjusted life years (DALYs) globally which represented 5.1% of all DALYs in that year1. It is known to cause more than 200

Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 30 Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 3011 (3): 35 – 38 communicable and non-communicable home-brewed alcohol (such as and diseases and injuries2. In 2011, there were more montoku) and later venture into drinking than 2 billion people worldwide consuming “western-style” beverages such as and alcoholic beverages and out of that 76.3 spirits8. Drinking alcohol is known to have million had an alcohol use disorder1. The some benefits such as helping to celebrate harmful use of alcohol caused an estimated 3 and socialize and enhancing the joyfulness million deaths globally in 20161. In the same of ceremonies9. It is also used as part of year, Malaysia was reported to be the tenth social, business, and family life, an enjoyable largest consumer of alcohol in the world3. and habitual accompaniment to food and Sabah is listed as having the third-highest celebrations. However, drinking alcohol to the prevalence of risky drinkers after Kuala Lumpur point of intoxication has not been reported to and Sarawak4. Alcohol is also associated with a be a part of tradition among these Indigenous significant reduction in quality of life, both for groups10. Moreover, according to Asmat individuals and communities1. Quality of life (2018)11, the abuse of alcohol can destroy the is an important parameter that provides an aim of these cultures. This pattern of drinking insight into how a disorder impacts the lives of contributes to serious health consequences2 those affected. and increases the chances of hurting oneself or others due to accidents, violence and suicide1. QoL is defined as a measure of the whole person, including physical and mental health According to Singh (2012)12, alcohol and social well-being1. A healthy QoL is not just consumption in Sabah peaks during the the absence of acute disease or chronic illness Kaamatan month (yearly in May) among but is re-conceived as a positive state of overall Kadazandusun communities. Kaamatan or subjective well-being. This concept involves Pesta Kaamatan is a form of harvest festival the dimensions of biological, psychological, which is celebrated annually by ethnic sociological and economic factors that include Kadazandusun in Sabah, Malaysia. Several a sense of achievement and mastery over activities are held during Kaamatan such as individual goals. It can also be an important cultural dance and music, traditional sports measure in tracking treatment outcomes for and games, carnivals and the grand Unduk alcohol use disorders5. Compromised quality Ngadau, otherwise known as Miss Kaamatan of life has been linked to depression, anxiety (Harvest Festival Queen). During most festivals and alcohol consumption6. According to in Sabah (including Kaamatan. and McCulloch (2006),6 many people alcohol New Year), alcohol prices are controlled by the to help deal with anxiety and depressive Government preventing traders from taking thinking patterns. advantage of the public and profiting by raising the price. Traders who are found not following In Sabah, alcohol is considered to be a the pricing set by the Government are fined. part of traditional culture, especially for some The culture of many Indigenous groups is of the Indigenous groups7. These Indigenous strongly connected to drinking alcohol but communities in Sabah, such as Kadazandusun, does not encourage abuse11. Research has Murut, Sungai and Rungus8, consider alcohol not previously been done looking at the role to be part of everyday life and as a key factor alcohol plays in the QoL of these communities in maintaining the culture and traditions7. A and this study aimed to address this gap in study found that youth in these Indigenous knowledge through exploring the role of groups start drinking at or before 15 years of alcohol in the lives of Indigenous groups from age8. They often start drinking the traditional the Western Division of Sabah.

20 Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, Sabah, Malaysia

MATERIALS AND METHODS Materials and Procedure

This qualitative study was using focus group The Diamond Dialogue tool by Willetts et al. discussions for the collection of data. The study (2018)14 (Figure 1) was used to identify the was conducted between 2016 and 2017 in impact of alcohol consumption on the health numerous villages in the West Coast Division. and quality of life of the Indigenous groups Communities were purposively selected for included in this study. It has been previously this study and identified as Kadazandusun, used as a research tool to evaluate the being an alcohol-consuming community, effectiveness of interventions in improving and having some awareness of the harms the quality of life in a variety of contexts14. caused by alcohol for their people. Participants Diamond Dialogue: A Tool to Explore Alcohol- included community members aged between related Harm and Strengthen Community 15 and 75. More females than males attended, Action10. The Diamond Dialogue is a diamond- and groups created were gender-specific and shaped tool, used to capture a diverse number of varied ages, with members from each village of perspectives during the discussions (Figure being placed in the same group where possible. 2). A happy face is placed at the top of the diamond representing “perfectly satisfied” Participants and Location and a sad face at the bottom representing “completely dissatisfied” with their sense of the Purposive sampling was applied to select quality of life. The researcher(s) begin by asking hazardous and harmful drinkers among participants about their definition of happiness the indigenous communities of Sabah. and unhappiness: “What does happiness mean As recommended by Babor et al. (2013)13 to you?”, “What does unhappiness mean to hazardous and harmful drinkers are suggested you?”, followed by identifying the factors that for brief education and brief intervention to influence “What makes you happy?”, “What reduce the alcohol related harm. By knowing makes you unhappy?”. Participants were then the impact of drinking style towards alcohol- asked about the effect alcohol has on the related harm would help to develop an quality of life in their community: “What’s appropriate intervention for further study. positive about alcohol?”, “What’s negative Screening by using AUDIT was done to about alcohol?”, “What role does alcohol play select participants who scored between 8 in your culture?”. Participants were also asked to 19 on AUDIT or known as hazardous and to mark on the diamond provided by the harmful drinkers. The data was collected in researcher(s) the happiest they had ever been one community meeting during the ‘Leaders and the saddest they had ever been between United Event of indigenous people of Sabah’ the extremes very happy and very unhappy. at PACOS-Trust located in Penampang, The Diamond Dialogue was used because it Sabah. PACOS-Trust stands for Partnership of was found to be a useful tool to allow each Community Organization. PACOS-Trust is a person to reflect and make their meaning community-based organization dedicated to in their discussion as well as getting rich supporting indigenous communities in Sabah. qualitative data15. Notes were also taken by the A total of 56 villagers from the communities researcher(s) in response to these questions. were involved in this study. In-depth focus group interviews were used to investigate the beneficial and adverse effects of alcohol on wellbeing in these communities.

21 Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 3011 (3): 35 – 38

Figure 1 Diamond with categories Figure 2 Example of Diamond Dialogue FigureFigure 2 Example 2 Example of Diamond of Diamond Dialogue Dialogue FigureNotes: This 1 Diamond figure withillustrates categories one of the diamond dialogue maps generated during a focus group discussion in the village. Figure 1 Diamond with categories Six villagers participated in the discussion. Each villager used a different colour pen to mark their response and their current subjective state of well-being. The happiest they had ever been marked with an X symbol and the saddest they had ever Notes: This figure illustrates one of the diamond dialogue maps generated during a focus group discussion Notes:been Thiswith figure symbol. illustrates one of the diamond dialogue maps generated during a focus group discussion in the village. Six villagers participated in the discussion. Each villager used a different colour pen in the village. Six villagers participated in the discussion. Each villager used a different colour pen to mark their response and their current subjective state of well-being. The happiest they had ever Data toAnalysis mark their response and their current subjective stateRESULTS of well -being. The happiest they had ever been marked with an X symbol and the saddest they had ever been with symbol. To identifybeen marked themes with and an subthemes, X symbol and transcript the saddest they hadAs for ever gender been with distribution, symbol. there was 29 female Datainterviews Analysis were entered into a qualitative data and 27 males participated in this study. For the analysis tool (Atlas.ti, version 7). The data was range age, 29 participants were in the range DataTo identify Analysis themes and subthemes, transcript interviews were entered into a qualitative data analysis tool (Atlas.ti,analysed version using 7). thematic The data analysiswas analysed to identify using thematic the analysisage to of identify 18 to 35the yearsfactors old, influencing while 27 participants Tofactors identify influencing themes and subthemes,alcohol consumption transcript interviews from werewere entered in the into range a qualitative age of data36 to analysis 55 years tool old. A alcohol consumption from the perspective of participants. The thematic analysis allows for understanding (Atlas.ti,the perspective version 7). of The participants. data was analysed The thematic using thematic total analysis of 24 to were identify single, the 29factors were influencing married, while theanalysis potential allows of any for issue understanding more widely. The the analysis potential followed an 3inductive were divorced. approach Thereincluding were coding, 51 Christian, while alcohol consumption from the perspective of participants. The thematic analysis allows for16 understanding writingof any comments issue more and memos,widely. familiarization, The analysis networkingfollowed and linking5 were and interpretation Muslim. As of for the datathe job. The sector, 32 were the potential of any issue more widely. The analysis followed an inductive approach including coding, analysisan inductive was conducted approach by the team including of researche rs,coding, with consultation self-employed, and negotiation enabling 6 working the formation with government, 16 writingofwriting the final comments comments themes exploredand andmemos, in memos, this familiarization, study. familiarization, networking andand linking 18 were and interpretationworking with of a the private data company.. The analysis networking was conducted and linking by the and team interpretation of researchers, withof consultationThere andwere negotiation 25 smoking enabling and the 31 formation were non- the data16. The analysis was conducted by the smoking (Table 1). Among the participants, 51 of the final themes explored in this study. team of researchers, with consultation and (91.1%) were Kadazandusun and 5 (8.9%) were negotiation enabling the formation of the final Bajau (Figure 3). themes explored in this study.

22 Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, Sabah, Malaysia

Table 1 Demographics of participants Variables Frequency Percentage (N = 56) (100%) Gender Female 29 51.8 Male 27 48.2 Age 18 – 35 years 29 51.8 36 – 55 years 27 Ethnic48.2 Group Status Single 24 42.7 Married 29 51.8 Divorce 3 5.5 Religion Christian 51 91.1 Muslim 5 8.9 Job sector Government 6 10.7 Private 18 32.2 Self-employed 32 57.1

Smoking Yes 25 Kadazandusun44.6 Bajau No 31 55.4 Figure 3 Ethnic group

and negatively to the overall QoL. These were Ethnic Group This study found five primary factors related to alcohol consumption in these communities which contribute both positivelylabelled and negatively health, to thebehavioural, overall QoL. These social, were economic labelled health, behavioural, social, economic and psychologicaland psychological (Figure 4.). (Figure 4.).

Health effects

Psychological Behavioural effects effects The beneficial and adverse effects of alcohol

Economic Social Kadazandusun Bajau effects effects

Figure 3 Ethnic group Figure 3 Ethnic group FigureFigure 4 The 4 The beneficial beneficial and and adverse adverse effects effects of alcohol of consumption alcohol consumption This study found five primary factors This study found five primary factors related to alcohol consumption in these communities which contribute related to alcohol consumption in these both positively and negatively to the overall QoL. These were labelled health, behavio ural, social, economic communities which contribute both positively and psychological (Figure 4.).

Health effects

Psychological Behavioural effects effects The beneficial and adverse effects of alcohol

Economic Social effects effects 23

Figure 4 The beneficial and adverse effects of alcohol consumption

Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 3011 (3): 35 – 38

Table 2 shows the five beneficial and adverse effects of alcohol consumption.

Table 2 The beneficial and adverse effects of alcohol Said by Said by Beneficial effects of alcohol K B Adverse effects of K B alcohol Health effects To mix with food (chicken ) Yes Loss of balance Yes Yes To treat disease Yes Headache Yes Yes Disease Yes Yes Premature death Yes Yes Behavioural To train the voice to sing Yes Yes Addiction Yes Yes effects To become brave Yes Yes Fighting Yes Yes To achieve goals in playing dart and reach Yes Family and domestic Yes Yes high notes in singing Yes violence Yes Yes Short temperedness Yes Yes Homeless Yes Yes Lies Yes Yes Family conflict Yes Yes Children neglected Yes Yes Loss of control Yes Yes Forgetfulness Yes Yes Irrational talk Yes Yes Waste of money and time Social To make new friends Yes Yes Accidents Yes Yes effects To spend time with friends and community Drunkenness Yes Yes More joyous Yes Yes Injuries Yes Yes Tighten relationship Yes Yes Danger to other Yes Yes To open conversation Yes Yes people Yes Yes Gathering Yes Yes Social problems To fill free time Yes Yes Yes Economic Business Yes Did not turn up for Yes Yes effects Tourist attraction Yes work Yes Yes Reduce performance Yes Yes Financial problem Psychological Satisfaction Yes Yes Unsatisfied Yes Yes effects Release stress and tired Yes Yes Jealousy Yes Express feelings Yes Depression Yes Yes Happy Yes Yes Distasteful to women Yes Note: K = Kadazandusun, B = Bajau

Health Factors groups also use alcohol for cooking, such as to According to participants, alcohol was mix with chicken soup. All participants agreed used to improve health and treat illnesses that a high intake of alcohol can have negative including reducing high blood pressure, to impacts on health for example stroke, gout, improve blood circulation, and for women loss of balance, diabetes and even premature post-delivery. Besides drinking alcohol, these death (Table 3).

24 Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, Sabah, Malaysia

Table 3 The quotes of positive and negative effects of alcohol on the health factor Factor Positive effects Negative effects Health “Our grandparents they drink alcohol to treat high “The bad aspect of drinking is gout, we call it GDL, blood, and after delivery, the lihing is more suitable to Gaut Datang Lagi (gout come again), it causes mix with chicken soup, but just a little bit.” (K) stroke and premature death.” (K) “When we drink whole the night, the next morning “There’s a grandpa who drank one or two can of we feel too sick to work, kougutan (drunk). When beer in a day, which he believed improve his blood we are kougutan we don’t have an appetite to eat, circulation which was impact very good, If he not has we don’t turn up to work, and lack of energy. So, fallen recently, I think he still would be quite well.” (K) all we can do is sleep.” (K, B) Note: K = Kadazandusun, B = Bajau

Behavioural Factors

Participants agreed that producing and consuming traditional alcohol is one of the ways they seek to maintain their culture. At the same time, participants reported that alcohol helps them to achieve goals such as to excel at playing darts, to reach the high notes singing karaoke, to prepare their voice to sing and to have more courage when talking about emotions and feelings. However, they also recognized that consuming alcohol excessively can lead to negative emotions (short temperedness), erratic thoughts, irrational talk, waste of money and time, family and domestic violence, fighting, accidents, homelessness and being addicted to the alcohol (Table 4).

Table 4 The quotes of positive and negative effects of alcohol on behavioural factor Factor Positive effects Negative effects Behavioural “If you get a bit drunk, you can reach the high notes. “Bad stories from the pass are reemerged when Same goes for playing dart, there are focus and you are drunk. The bad are irrational and hurtful concentration.” (K, B) talk which end up with fighting.” (K, B) “When you get drunk it can cause fighting, “When drunk, we can talk more easily, and we are not accidents, injuries, danger to other people who afraid to talk.” (K, B) do not drink. Like in road or a celebration.” (K, B) Note: K = Kadazandusun, B = Bajau

Social Factors

Alcohol is reported by participants to be an important part of socializing and is used to help make new friends, to open conversations, to tighten relationships, to have time with friends and family as well as to make parties or festive ceremonies more joyous. Alcohol is also recognised to negatively influence behaviour when people become intoxicated. It can lead to fighting and accidents, and danger to oneself and other people such as injuries caused by fighting and road traffic accidents as well as unplanned and unprotected sex (Table 5).

Table 5 The quotes of positive and negative effects of alcohol on the social factor Factor Positive effects Negative effects Social “The bad effects of alcohol are getting drunk, “To tighten the relationship with friends and to get easily getting angry, erratic thoughts, always know strangers.” (K, B) wasting money, forgetfulness.” (K, B) “About accident, if too drunk, getting “Drinking is crucial to Kadazandusun culture, you involve in an accident if you are too drunk. enjoy events with family and friends more if alcohol Most of them die, only a few survived.” is included.” (K) (K, B) Note: K = Kadazandusun, B = Bajau

25 Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 3011 (3): 35 – 38

Economic Factors can also cause financial problems either through the cost of purchasing commercial Participants discussed how alcohol can alcohol or the cost of treating illnesses caused provide benefits in terms of business and as by excessive consumption of alcohol. There are a tourist attraction. The groups interviewed also indirect costs such as poor work and/or agreed that alcohol is a viable source of study performance and the impact of conflicts income for those producing and selling it. or domestic violence. Participants in this study They claimed that tourists often want to try claimed that some people did not turn up for the locally produced alcohol. However, alcohol work due to drunkenness or being hung-over (or kougutan) (Table 6).

Table 6 The quotes of positive and negative effects of alcohol on the economic factor Factor Positive effects Negative effects Economic “When drinking alone we can control our alcohol “Tourism product, cause some white people looking consumption and expense. But when in a group for lihing right.” (K) some members may not contribute financially and leave others ‘out of pocket’.” (K, B) “When you get drunk, you don’t realise hit your “I asked at Sabindo store and they told me that they wife or your child, pounding the wall or damaging can sell 2 to 3 hundred crates of Hollandia in a day.” (K) furniture in the house (TV, table, chair, etc.).” (K, B) Note: K = Kadazandusun, B = Bajau

Psychological Factors

Moderate alcohol consumption may provide some psychological benefits such as to help release stress and to recover from tiredness after working long hours. Moderate consumption can also enhance positive emotions. Participants also reported that some people suddenly dare to talk in unfamiliar language, such as English, when they have been drinking. Drinking too much alcohol can lead to loss of memory (for example having no recall of the events from the previous evening), negative emotions (easily becoming angry), family conflict and some of male participants said that it is sometimes distasteful to women (no women like men who are always drunk) (Table 7).

Table 7 The quotes of positive and negative effects of alcohol on the psychological factor Factor Positive effects Negative effects Psychological “If sometimes we’re tired, and stressed, we feel a bit “Ya, the fighting between husband and wife. released after drinking.” (K, B) Kids can be neglected if overdrinking.” (K, B) “If you get a bit drunk, you dare to talk in English and “Feel happy only during the drinking but after even having a conversation in English” (K, B) that easy to get mad.” (K, B) Note: K = Kadazandusun, B = Bajau

DISCUSSION effects become evident when individuals drink excessively over long periods or engage in The results revealed five categories of beneficial heavy episodic drinking. The results from this and adverse effects of alcohol consumption study confirm previous findings in the literature including health, behavioural, social, economic which report that alcohol can have both and psychological factors, depending on the positive and negative effects2, 17. The harmful pattern of the individual alcohol consumer. use of alcohol affects not only the drinker This study found that moderate alcohol but also has negative effects on other people consumption can provide some benefit for around the drinker: their family or household individuals and communities. However, adverse and the wider community.

26 Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, Sabah, Malaysia

Health Effects of Alcohol Consumption Behavioural Effects of Alcohol Consumption

We found that some of the Indigenous groups The present study found that drinking small of Sabah use alcohol for cooking food and amounts of alcohol provides benefits in terms improving some health conditions. These of positive behavioural effects for individuals Indigenous groups believe that alcohol can be (e.g. to have the courage to talk about used to treat some illness (such as to treat high emotions and feelings, to reach the high notes blood pressure) and is beneficial for women when singing, or to excel at playing darts). after birth delivery (to heat their body). These These findings are supported by the results findings support the results from a previous of a previous study that found moderate study that the benefits of moderate alcohol alcohol consumption can help in making consumption1 provide some health benefits new friends10, 19, and can improve other social to the body such as lowering risks for total activities through increasing the ability to mortality, coronary artery disease, diabetes laugh, to sing and to dance20. It was also found mellitus, congestive heart failure, and stroke17. that heavy alcohol consumption contributes Moderate alcohol consumption may also give to many behavioural problems such as protection against heart attack, coronary fighting, family and domestic violence, family vascular disease, ischaemic stroke and death conflict, neglect of children, addiction, etc. As from cardiovascular causes18. found in other studies, increased behavioural problems include intentional injuries such as However, the harmful use of alcohol self-harm, suicide and interpersonal violence contributes to health consequences such as well as unintentional injuries such as road as arrhythmias, heart failure, elevates blood traffic injuries, drowning, burns, poisoning, pressure, stroke, diabetes and increased risk of falls21, as well as unintentional self-harm and breast cancer for women17. According to WHO1, interpersonal violence attributable to alcohol the harmful use of alcohol contributed to the consumption22. estimated 3 million alcohol-attributable deaths globally in 2016. These deaths are reported to The alcohol harm occurs not only to the occur due to digestive diseases, unintentional drinker but also to the people around them, injuries, cardiovascular diseases and diabetes including her or his close family, relatives and with the highest percentage of digestive friends, as well as to other road users1. Previous diseases (21.3%) and unintentional injuries studies state that regular heavy alcohol (20.9%), followed by cardiovascular diseases consumption and heavy episodic drinking are and diabetes (19.0%), infectious diseases associated with increased physical problems, (12.9%), malignant neoplasms (12.6%), antisocial behaviour, violence, accidents, intentional injuries (7.8%), alcohol use disorder suicide, injuries and road traffic crashes23. (4.9%) and epilepsy (0.6%). In addition, the 2018 Global status report on alcohol and health Social Effects of Alcohol Consumption includes the contribution of some infectious diseases to all alcohol-attributable deaths. This study found that alcohol consumption in Alcohol has also been shown to increase the these Indigenous groups is influenced by social risk of unplanned and unprotected sex17 and factors (e.g. forming new friendships network, mortality risk from HIV/AIDS. having time to relax, tightened relationships with friends, etc.). It can be described by the Actor-Network Theory (ANT), where people are willing to connect with others and to interact with their environment24. According to ANT, we cannot ignore the web of connections

27 Borneo Journal of Medical Sciences 14 (2) May, 2020: 19 – 3011 (3): 35 – 38 between all things, both human and non- at producing such . Nevertheless, it also human. In this study, it suggests that in a given reported being the cause of financial problems social network, the actors, or the Indigenous for some people, either through the cost of people of Sabah are influenced not only by purchasing commercial alcohol or the cost of each other but by other non-person factors treating illnesses caused by excessive alcohol like alcohol. A study found that some of the consumption. Although Malaysia is a Muslim Indigenous groups of Sabah use alcohol majority country, the country’s population to improve social connectedness, in social still consumes a high level of alcohol and events, and in helping them be more outgoing permits the selling of alcohol to people who in social situations10. are not Muslim26. Malaysia was reported as the tenth highest alcohol consumption of alcohol People need to have a connection to per capita worldwide by the World Health and interact with their environment, where Organization, with annual spending estimated they can feel a sense of belonging or being RM2 billion on alcohol beverages1. appreciated by the community. It is stated in Maslow’s Hierarchy of Needs25 that in the third Price is known to be one factor that stage of human needs, love and belonging can impact alcohol consumption and are key factors for successful progression in alcohol-related harm27. In general, lower life. According to Maslow’s Hierarchy of Needs, socioeconomic groups experience higher people need a sense of belonging, receiving levels of alcohol-related harm than wealthier and giving love, as well as appreciation and groups with the same level of alcohol friendship. As found in this study, having consumption1. Socioeconomic status is one alcohol with others is an opportunity for the of the various factors that influence a person’s participants to socialise with friends, to make consumption of alcohol and outcomes. To new friends and also to tighten the relationship reduce harmful alcohol consumption and with friends and community. A study found alcohol-related harm, governments and other that peer pressure and social influence can stakeholders recommend taking collective have a powerful role in individuals choosing action (e.g. to collaborate with the Secretariat to drink, particularly in situations where in developing a draft global strategy on alcohol is used or it is a part of socialising harmful use of alcohol, to develop interaction with friends9. Participants of the study also with relevant stakeholders, national systems recognised that some of them were drinking for monitoring alcohol consumption, to too much alcohol which eventually caused consider strengthening national responses, to negative effects, not only to themselves but prepare a draft global strategy to reduce the also to their environment, their families and harmful use of alcohol, etc.) to support and the community as a whole. These findings are empower communities28. similar to those found in the previous studies40 that report alcohol-related harm occurs not Psychological Effects of Alcohol only to the drinker. Consumption

Economic Effects of Alcohol Consumption Alcohol consumption and depression are correlated to some degree while recognizing Alcohol was also reported by participants as that this association is extremely complex29. providing benefits in terms of business and as Although no participant reported drinking a tourist attraction. The local alcoholic drinks in being directly related to depressed mood, Sabah (e.g. bahar, lihing, kinupi, tapai, montoku some participants reported they consume and sikat) have become a tourist attraction and alcohol to provide relief from feeling stressed can generate income for those who are skilled and tired, to feel happy, to express feelings, or

28 Effects of Alcohol towards Quality of Life in the Indigenous Groups of the West Coast Division, Sabah, Malaysia to feel satisfaction. These findings are in line ACKNOWLEDGEMENTS with other literature that reports many people experiencing anxiety or depression intentionally This study was financially supported by the consume alcohol to reduce their stress and Ministry of Education, Malaysia through the improve mood30. A study found some of the scholarship Mybrain15. We thank the head Indigenous groups of Sabah consume alcohol of villages for permitting to conduct this to improve their quality of life10. It also reported study in their village. We also appreciate all that alcohol was found as a key ingredient in villagers for participation and information their happiness, whereas, without alcohol, they given in this study. believed their life to be uninteresting10.

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